US residency requirements for IMGs: the 3 things you need, and why letters decide it

If you're a medical student who wants to do residency in the US, let me explain it simply.

To apply for residency in the US, there are three things you must have:

1. A medical degree (MBBS or MD) from an accredited medical school.
2. USMLE Step 1 and Step 2 passed.
3. Three letters of recommendation.

That third one matters a lot, and it makes a real difference to whether you match. Not just any letter will do: you need three strong, high-quality letters from physicians in the US.

You don't have to do these one after another. Observerships and research can start while you're still a student, alongside your degree and your Step exams.

For the full path in order, from ECFMG certification to ERAS and Match Day, see the US residency path for IMGs, step by step.

How do you get them?

There are two main routes:

• An observership, where you shadow a physician in the US and follow their work.
• Research, where you work with them on a project.

This is where IMG Outreach comes in.

Why the number of emails matters

Most physicians won't reply to your first email, so you need to write to a lot of them.

Doing that by hand is exhausting. You have to write every email yourself, and before each one you have to look up the physician's background: their specialty, where they work, what they've researched. That's how you write an email that catches their attention and shows you're genuinely interested in their work, so they want to reply.

One email like that can take a long time. Now imagine doing it for hundreds of physicians.

IMG Outreach does that work for you. You can send a very large number of emails, and each one is written for the physician it goes to, about their background and their research, not copy and paste. Instead of spending days searching and writing, you can send, say, 500 emails. If even a small share of them reply and say yes, you've caught the opportunity that gets you the letters you need.

Simply put: the more you send, the better your chance of getting in.

Frequently asked questions

What do IMGs need to apply for US residency?

A medical degree from an accredited school, USMLE Step 1 and Step 2 passed, and usually three letters of recommendation. US letters from physicians in your specialty carry the most weight.

How do IMGs get US letters of recommendation?

Mostly through observerships, where you shadow a US physician, and research, where you work with them on a project. Both usually start with a cold email to the physician.

Can I start observerships before finishing my degree or USMLE?

Yes. Observerships and research can run alongside your degree and your Step exams; you don't have to do them one after another.

How many physicians should I email?

Many. Most physicians won't reply to a first email, so students who land observerships usually write to dozens or hundreds, with each email written for that physician. See our guide on how to email a doctor for an observership.